Patient meets criteria for severe opiate use disorder by DSM 5 criteria. Risks/benefits/alternatives were discussed in detail and patient has made an informed decision to begin buprenorphine.
· Check HIV/HCV/HBV/LFTs/Utox/Preg test if not done
· If pregnant, obtain FHTs or NST as indicated
· Request an ADTS consult. Educated on harm reduction.
· Educate patient and RN that buprenorphine is a sublingual formulation and proper technique.
· Ensure patient has had NO opiates for at least 6 hours (short acting). Note, long acting opiates and methadone may take up to 36 hours for the initiation of withdrawal.
· Day 1: Check COWS when in withdrawal:
o if <8, reassess every 2 hours while awake until COWS >8
o Once >/= 8
§ administer 4mg of buprenorphine/naloxone and reassess COWS in 1.5 hours.
· COWS <8: reassess in 6 hours as needed
· COWS >/=8, dose again and then reassess every 6 hours as needed
o Can repeat COWS and dosing every 6 hours as needed
o Max dose day 1= 16mg total (average 8-12 mg)
· Day 2: Give total Day 1 dose on Day 2 as a once daily dose in the AM.
o May add an additional 2-4 mg as needed throughout the day
o Max dose day 2= 20mg total
· Day 3+: Give total Day 2 dose on Day 3 as a once daily dose in the AM unless divided dosing needed for pain/anxiety.
o Max dose 24mg
- May divide dosing as needed for pain/anxiety. May decrease dose as needed for any adverse effects.
- By 72 hours, ensure an x-waiver provider is involved in this case. Prior to 72 hours, any provider may begin buprenorphine.
** Caution: Expert consultation for any of the below:
- In pregnancy, use buprenorphine mono-product
- If methadone used in past week
- LFTs >5x ULN
- Surgery/Procedure in next 48 hours
- Severe acute pain (mild-mod pain can consider splitting dose to BID-q6) or adding a full agonist PRN (hydromorphone or fentanyl)
- recent use of other sedatives (benzodiazepines, barbiturates, z-drugs, opiates, EtOH)
The following adjunctive medications can be used for symptom control:
- acetaminophen 650mg q6 prn pain (as tolerated by LFTs).
- clonidine 0.1-0.3 mg PO q6-8 hours prn vasomotor symptoms (hold if BP< 100/70 and NTE 1.2 mg/day).
- hydroxyzine 25mg po q6 hours prn anxiety.
- trazadone 50-100mg po qhs prn insomnia.
- loperamide 4mg po initially, then 2 mg PRN each additional loose stool (NTE 16mg/24 hours).
- ondansetron 4mg po/SL/IV q6 hours prn nausea.
- melatonin 3mg po qhs prn insomnia.
- Please provide enough Rx for patient to last until an appointment with a bup provider. Rx must come from a x-waivered provider. Appointment with bup provider should be within 1 week and max Rx given should be a 7 day supply.
- Provide discharge rx for nasal naloxone.
- Consider PEP for HIV if indicated.